The Pharmaceutical Journal Vol 264 No 7100 p888-889
June 10, 2000 Articles

Tackling the obesity epidemic - an update

By Pamela Mason, PhD, MRPharmS

The United Kingdom has the most rapidly increasing obesity problem of any country in Europe. This article discusses ways of tackling and diagnosing obesity and preventing and managing the condition through diet and exercise

The whole of the developed world - and increasingly parts of the less developed world, too - is experiencing an obesity epidemic. This is especially so in the United Kingdom, which has the most rapidly increasing obesity problem of any country in Europe. In England between 1990 and 1997 the number of overweight men increased from 39 to 65 per cent of the population and of women from 32 to 53 per cent. The prevalence of obesity increased from 6 to 17 per cent in men and from 8 to 20 per cent in women. Interestingly, this increase has occurred in a context of falling energy intake over the past 20 years and a public that is better informed on healthy eating. The obesity epidemic is therefore thought to be mainly due to reduced physical activity levels, although other factors - both environmental and genetic - play a part. Body weight is regulated by a series of physiological mechanisms, although environmental factors undoubtedly influence both energy intake and expenditure and overwhelm these mechanisms. In addition, some people seem to be more susceptible to weight gain than others and genetic factors may also play a part. However, the rapid increases in obesity have occurred in too short a time for there to have been significant genetic changes within populations and the fundamental principles of energy balance, ie, that energy intake must exceed energy expenditure for an individual to gain weight, are irrefutable. Whatever the causes of obesity, the costs - health, social and economic - are considerable. According to work conducted by the National Audit Office, which will be published later this year, the direct costs of diagnosis and treatment of obesity and overweight are likely to be around 2-4 per cent of total NHS expenditure.1 These figures do not include costs to the individual due to the impact of obesity, and the conditions it may cause, on quality of life.

Tackling obesity

Not surprisingly, in the UK obesity is increasingly being recognised as a problem to be tackled. During the past few years, it has been the subject of reports from the Royal College of Physicians, the Scottish Intercollegiate Guidelines Network and the World Health Organisation. Obesity is also implicit in the current health strategies for England, Scotland, Wales and Northern Ireland. All these strategies recommend action at both local and national level. The main vehicles for tackling these priorities at a local level are the health improvement programmes.
Many pharmacists are involved in giving advice to the public on the prevention and management of obesity. However, it is worthwhile finding out what is going on in the locality and keying in to any local strategies or campaigns - or being proactive and initiating new ones in partnership with primary care groups or trusts and other local agencies, such as leisure centres, food retailers, local authorities and so on.
Ms Carole Macguire (community pharmacist, Moss Chemist, High Peak, Derbyshire) is working to encourage healthy eating and physical activity in her district. Many of her customers are on low incomes and she is trying to arrange a voucher scheme with local greengrocers to allow people 10 per cent off their fruit and vegetables. She has also encouraged a few people to keep food diaries and then got them to assess for themselves how they could improve their diet.
Working with a personal trainer, Ms Macguire is also involved in running exercise classes, and, having recently found out that North Derbyshire health authority arranges "exercise walks", she is encouraging her customers to go on these. "It's really important to find out what is available in your area," she says.

Diagnosis

Pharmacists can have a role in identifying groups of people at special risk - either at risk of becoming obese or at special risk from being obese. These include people on low incomes, who may have poor diets high in fat and energy, elderly people with arthritis, who can maintain mobility more easily if they maintain a healthy weight, and Asian people, who are at particular risk of diabetes and cardiovascular disease.
Body fatness can be assessed by several methods, of which the body mass index [BMI = weight (kg)/height (m)²] is now the most commonly used. However, measurement of the BMI has several limitations, including the fact that it does not assess the distribution of fat. Abdominal fat in particular is a risk factor for chronic conditions such as such as cardiovascular disease and obesity. Other measures such as waist circumference, waist/hip ratio and waist/height ratio have also been proposed because they may help to give an indication of regional fat distribution. As a starting point, pharmacists could consider keeping patient's BMIs and/or waist circumferences as part of their medication records.

Prevention and management

Prevention of weight gain is now considered to be as important as management of obesity and overweight, and a healthy, low fat diet together with daily physical activity are important routes to prevention. The American College of Sports Medicine (ACSM) has recently recommended that people should "accumulate 30 minutes of moderate to vigorous activity daily or on most days." Going to the gym, swimming, playing sport, jogging and aerobics are all fine except that many people find it difficult to fit such activities into their daily lives and the best laid plans often come to nothing within a matter of weeks.
Mr Rob Cowling (exercise physiologist, Cape Town University, South Africa), who spoke at a recent obesity training day for health professionals (organised by Lynda Price Associates), says that one of the current challenges for obesity prevention is to increase spontaneous physical activity. This could mean walking to work, getting off the bus a couple of stops earlier than usual, walking up the stairs rather than taking the lift and so on. The idea is to inculcate regular physical activity as a way of life, rather than, for example, driving to the gym once a week, parking the car as near to the entrance as possible and then indulging yourself with a bar of chocolate by way of a treat, he adds.
Diet remains the cornerstone of obesity management, but the emphasis should be on gradual weight loss. And although achievement of a BMI within the 20-25 range is beneficial for an obese individual, even a 10 per cent weight loss is beneficial in terms of disease risk reduction. The problem with setting people weight targets within the "ideal" range is that they can so easily be set up to fail, and this can reduce self esteem. Targets of this sort can also encourage weight cycling, which may be as great a risk factor for cardiovascular disease and other conditions as being obese.
Although weight cannot be lost without reducing energy intake below energy expenditure, fat is the main dietary component to target. This is not only because fat provides the most calories on a weight-for-weight basis, but also because it appears to be more easily stored as body fat than the equivalent number of calories from protein or carbohydrate. And, as with physical activity, the idea is to encourage healthy, low fat eating as a way of life.
Regular physical activity is also important for management of obesity. Diet alone will lead to weight reduction, but in comparison to diet and exercise, diet alone leads to a greater reduction in fat free mass (ie, muscle) relative to fat and therefore reduces basal metabolic rate (BMR). This puts individuals at a disadvantage for maintaining their weight after excess weight has been lost, and there is therefore something in the saying that "dieting makes you fat". Diet in conjunction with exercise represents the best approach.

Exercise prescriptions

Getting an inactive person to take exercise is not always easy, and additional help and motivation are sometimes required. Exercise programmes - often based in leisure centres - are increasingly available, and some GPs prescribe them. What generally happens is that the GP gives a prescription to the patient, who then takes up an appointment with the leader of the scheme. The patient's exercise needs are assessed and an appropriate exercise programme devised. This can include walking, dancing, swimming, football, tai chi and so on, and the cost of the programme to patients is normally that of an NHS prescription, unless they are exempt, when they get it free of charge.
In 1996, about 200 exercise schemes were available in Britain, and a review of these schemes showed that they were generally successful in attracting patients, increased short-term physical activity and fitness and improved general well being.² However, few of the programmes have been rigorously evaluated and more research is required to establish their long-term cost effectiveness.
The British Heart Foundation, together with the Countryside Agency, has recently obtained a grant of £6.4m from the New Opportunities Fund to develop and support around 200 community based "walking for health schemes". The schemes will involve walks of around two miles or less. They will be launched from September and will focus on areas of health inequality in cities, towns and rural areas.
The British Heart Foundation has also published a report, "Couch kids: the growing epidemic" (see p872), which highlights the importance of physical activity for young people. These recommendations are important in the light of the recently published National Diet and Nutrition Survey (NDNS) which showed that most youngsters over the age of seven are not meeting the recommended one hour's activity a day.

South African programme

A new programme, described by Mr Cowling at the obesity management training day, uses a similar approach, in that GPs can refer patients to it. However, the focus is not weight loss per se, but risk reduction of diseases such as diabetes and cardiovascular disease. Mr Cowling thinks that the traditional weight centred approach generally fails and that what is needed is an approach that can produce health benefits independently of weight loss.
The programme, which includes both exercise and diet as appropriate for each patient, is currently being piloted in eight centres in the community, and results will be available during the next 12 months. Patients are helped by a facilitator to assess their attitude to exercise using a behaviour change model. In other words, patients may be "pre-contemplators" with no intention to exercise, "contemplators" who are thinking of exercising or have already started or "active" and exercising regularly three or more times a week.
The facilitators are not health professionals in the sense that they are not nurses, doctors or dietitians. But they have skills in counselling and helping the patient to achieve self reliance in managing their diet and exercise programme and they often do this better than health professionals, Mr Cowling, says. In short, they are good "hand holders" and the aim is to inculcate exercise and healthy eating as a way of life within a period of three to six months. Any patients with medical problems are referred to doctors acting as consultants to the programme.

Conclusion

The obesity epidemic needs to be tackled. A variety of approaches are needed and should involve partnerships between different professionals and other agencies. One way for pharmacists to get involved is through the health improvement programme, and it is also worth building up a list of resources available in the locality, such as exercise programmes and organised walks, which could help people reduce weight and improve health.

Dr Mason is a pharmacist with a postgraduate qualification in nutrition

References